Abstract
This case describes a rare instance of reversible dilated cardiomyopathy (DCM) in a 65-year-old Caucasian male with a significant past medical history of inflammatory rheumatoid arthritis (RA) controlled with rituximab and hydroxychloroquine (HCQ). The patient presented with acute onset of dyspnea on exertion and palpitations and was diagnosed with congestive heart failure in the context of DCM. Despite having no prior cardiac abnormalities, an EKG revealed a new left bundle branch block, and an echocardiogram demonstrated a severely reduced left ventricular ejection fraction (LVEF) of 10-15%. Left heart catheterization and coronary angiography revealed no evidence of coronary artery disease. Given the absence of an overt cause, drug-induced DCM was suspected; hence, rituximab and HCQ were discontinued. Other common causes of DCM, including alcohol abuse and virus-induced DCM, were excluded based on relevant testing. Seven to nine months after cessation of HCQ and rituximab, the patient's RA progressed, and treatment was initiated with IV tocilizumab, resulting in a good clinical response. At the 26-month follow-up, a repeat echocardiogram revealed mild mitral regurgitation with an LVEF which improved to 55%. At this point, Takotsubo cardiomyopathy was considered a potential cause of this patient's DCM due to its reversible nature. This case highlights the importance of comprehensive cardiac monitoring in symptomatic patients at high risk for cardiovascular disease, such as this patient with long-standing inflammatory disease. Physicians should work together to closely monitor and consider the serious potential risks of all treatment regimens.